Night to Shine Participant Registration and Contact Form 

A. Guest Information
Name *
Name
Gender *
Gender
Address
Address
Phone *
Phone
Emergency Contact Phone:
Emergency Contact Phone:
Special Communication Needs: *
B. Allergies
C. Food/Medication/Transportation Needs
Food Needs (food cut-up, pureed, gluten free, etc.): *
* Please note that the church, their staff and volunteers are not responsible for pureeing food or feeding guests during the Night to Shine event. A parent or caretaker MUST be available to do so.
Will Need Medication Administered During Event: *
* Please note that the church, their staff and volunteers are not responsible for administering medication to guests during the Night to Shine event. If medication is required during the event, a parent or caretaker MUST be available to administer the medication.
Will guest be dropped off and picked up by a parent/caretaker? *
Will guest be taking public transportation to and from event?
Will guest be attending as a part of a group that will provide transportation? *
D. Parent/Caretaker Information
Parent/Caretaker will be… *
* The Respite Room is a private area where parents/caretakers of guests can spend the evening enjoying food, entertainment and rest while remaining onsite during the event.
E. Care Provider Agency Information – If Applicable
*Please note-If attending as a part of a group, please include agency or company name.
Care Provider Agency Phone: *
Care Provider Agency Phone:
*Please note-Chaperone is not required to stay with guest(s) unless required by Care Provider Agency or to assist with feeding/medical and/or communication needs.
Remit completed Night to Shine Participant Registration and Contact Form, Night to Shine Participant Media Rights Release and Night To Shine Parent/Caretaker Media Rights Release no later than December 3rd, 2018
Guest Registration Checklist
Please complete the following paperwork when registering each guest. Registration will not be accepted until all paperwork is filled out completely, signed and returned no later than December 3rd, 2018. Thank you! Night to Shine Participant Registration and Contact Form Night to Shine Participant Media Rights Release Night to Shine Parent/Caretaker Media Rights Release